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805 Will Boone Rd . . DAVIE COUNTY HEALTH DEPARTMENT � 10-IS-q� . ` ► Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 �;�� (336)751-8760 f1,��Y �'8���� ��,�IPROVEMENT/OPERATION PERMIT .� Account #: 989900063 Tax PIN/EH#: 5756-06-1575 �,,� Billed To: Larry McDaniei Subdivision Info: �5 ��il/ �0C/'�„�° ��GN Reference Name: Janice or Larry McDaniei Location/Address: Will Boone Road-27028 Proposed Facitity: Resldence Property Size: 2.939 Acres ATC Number: 2190 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �jj�(,�S� #People #Bedrooms�_ #Baths� Dishwasher:� Garbage Disposal: ❑ Washing Machine:�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��� Type Water Supply �0 Design Wastewater Flow(GPD) Lj 6(� Site: New� Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth��Linear Ft�DO� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** � � Environmental Health Specialist's Signature: �) Date: /U�S� l �� DCHD OS/99(Revised) � . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900063 Tax PIN/EH#: 5756-06-1575 Billed To: Larry McDaniel Subdivision Info: ' Reference Name: Janice or Larry McDaniel Location/Address: Wiil Boone Road-27028 Proposed Facility: Residence Property Size: 2.939 Acres ATC Number: 2190 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA R ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � Date: ��l,S�/9� CERTIFICATE OF COMPLETION **NOTE** 'The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. /�e�,� F Q Septic System Installed By: , 1 C I Environmental Health Specialist's Signature: � Date:�/,�— ���� DCHD OS/99(Revised) - � t . . • • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE I��t-�� � � � Davie County Health Department � �� � Environmental Health Section P.O. Box 848 SEP 2 Q ��� Mocksville,NC 27028 , M (704) 634-8760 Er�v►Ror�rAEPlTAL HEA H DAVIE COU��TY ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL �+� THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �rl"L l rn��-I����c�v�S.�.�Contact Person___�r��J � V�-�1�C� m�'����C� Mailing Address�-�• lr�'�C �]� Home Phone ���LQ — ����Q� c� City/State/Zip �k�U ���Q.. , ��-o�-�l»� Business Phone ��P —`7S1' �I da-� 2. Name on PermidATC if Different than Above Mailing Address City/State/Zip 3. Applicadon For: [ j Site Evaluation [ j Improvement Permit&ATC [�Both 4. System to Serve: [�House [ ]Mobile Home [ ]Business [ ]Industry [ j Other �f'� �;;� 5. If Residence: #People #Bedrooms�� #Bathrooms � [rj Dishwasher[ ]Gazbage Disposal i;;: ;� [y]�Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type �I 1� #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) , 7. Type of water supply: Count City [ ]Well [ J Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [vj No ' If yes,what type? EZ THER tl PLAT OR S Z TE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT**'��'OF THE PROPERTY MUST BE �. SUBMITTED WITH Ii�S APPLICATIOl�: Property Dimensions: � 0���35F�C;W��DIRECTIONS(from ocksville)TO PROPERTY: Tax Office PIN: #.�- p�F - �� � � J` Q 6 I � `�YS E�.�7 d� Property Address: Road Name �� �� ��� �-tl � �(�M �— (JLt g ' � � City/Zip �M OC�CS V�`�Q_ T�� �-��; — i b D If in Subdivision provide information,as follows: ��.1 (r� j � �J 6 o e� � � Name: � �-, G,� � S 6 r �—e /"a � � Section• Lot#: � � — � � This is to certify that the information provided is conect to the best of my knowledge. I understand that any permit(s) issued hereafter aze subject to suspension or revocation,if the site plans or intended use change,or if t6e information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by � `��`i L� ���r�c�c� . Sl�,r�to con testing procedures as necessary to determine the site suitability. DATE � �o� a 9 SIGNATURE �� {�� Revised DCHD(06-96) . THZS AREA M,41f $E USEb �OR �RttWINC7 iJOUR SZTE PL,4N: ; C�t���-� �e� �'�'►� c.�t� � r a�w�;� � — f�- � �---- 1 � � ��� � 9�/ � : . ,, ;. �� s � . � ��6I� �� r•(�X���T"�i y�y%�'e.f�'�i�'�. A ;C, •�Y,4�'f`ri'�J�. ,•� D",ir��ti'S``',`�s ��' "� � � � Ce62 L � , This map is for PERC TEST and BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office � assumes no liability for any information contained on this map �� 32 ` COUNTY-ID:L80000000401 � September 20,199910:17 AM � Parcel Identification Number 0nB2 5756-06-1575 r . � � N � � (2. 82A) 1575 32�` 200 ` � � N M � Scale:l"_ ••••"•••"• September 20,199910:09 AM , ,.. ,. �• � ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Heolth Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900063 Tax PIN/EH#: 5756-06-1575 Billed To: Larry McDaniel Subdivision Info: Reference Name: Janice or Larry McDaniel Location/Address: Will Boone Road-27028 Proposed Facility: Residence Property Size: 2.939 Acres Date Evaluated: � C' Water Supply: On-Site Well Community Public v Evaluation By: Auger Boring '�� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L, Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �' �� Texture rou Consistence � Structure / . /i' Mineralo ,'/ .� HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � `' i r SITE CLASSIFICATION: EVALUATION BY: Cc'� LONG-TERM ACCEPTANCE RATE: I b OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Mois VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S -Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) , LTAR-Long-term acceptance rate-gaUday/ft2 DC�ID OS/99(Revised) ■�����/�■���■■�■������■■■��■■■�������■■■■������■�■■���■■■����■�■■■ ■��■�����0�■�■��■■�■��■�■���■���■���■■■��������■����■■�■�■�����■�■ ■�■�����■■�■�■��■�������■���■■����■�■���■�������■��■�■■�■�����■�■ ■���■■��■������■���■■■�■�����■�■ ■■�■■��■�■■�■■■�■�■��■■��■ ■�■�■ ■���������■�■��■���a■�■■��■�■■��■��■■■■��■�■■■■�■�e�■■�■��■�■�■��■ ■����■■����■���■���■■�����■��■�■■��■�����■■■�■��■�■■�■■�■����■���■ ■���■�■��■■�����■�■��■��■��■�■���■�■■�■��■���■�v■o■■�■■�����s■�■�■ ■■■��■■■o���se��■�s■■������■��■��■�■��■��■e�s��s■■���a■�■���■■■��■ ■����■��■�■�■�■�■■��■�■��■��■■■��■��■�■�■■■�����■��■■���■��■■■���■ 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